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2020-03-31

Alone Against the Virus

Decades of neoliberal austerity will make it harder to fight the COVID-19 pandemic. Now, more than ever, we must rebuild our social safety net and forge a New Deal for public health.

The social safety net that Republicans and neoliberal Democrats love to hate is what undergirds successful health systems, and rebuilding it will be the foundation of a New Deal for Public Health.

The enormity of the coronavirus pandemic is still unfolding. The true toll of COVID-19 won’t be known for many months, but the best-case scenario is probably roughly ten times as bad as a severe flu season, with a particularly brutal impact on the elderly and sick.

As governments around the world scramble to contain its spread, entire cities have been sealed off. Schools have been closed. Hundreds of thousands—in all likelihood, millions—of people are in quarantine. The U.S. response has been delayed, perhaps catastrophically, by failures in the scale-up of testing for the virus. We have no valid estimates—not even within orders of magnitude—of the number of infections here. But cities and localities are beginning to follow what businesses and universities had already begun to do: recommending or mandating “social distancing” measures such as limits on public events to stave off a tidal wave of sickness that could swamp our health care system.

Though we’ve had months to prepare, we have yet to reckon with the extraordinary risks that a pandemic like this poses in a country like ours. Those hardest hit will be the most vulnerable—the elderly and those with chronic diseases, particularly those in nursing homes, crowded homeless shelters, and prisons. We have no natural immunity to this new virus, and there is no vaccine. It will spread unchecked, from human to human and across our social gradients, unless we create social immunity, woven of the ways we interact and care for one another. But what kind of social immunity can we build in a body politic that has been ravaged for decades by neoliberal policies?

Those policies have delivered us a rapaciously profit-driven health care system, a hyper-carceral approach to migration and social dislocation, an austerity-ravaged state that looks ever more like the neoliberal caricature, and a crisis of social reproduction. At every step, these conditions will make this virus harder to manage. We have known since the work of Rudolf Virchow, who studied typhus in Upper Silesia in the mid-nineteenth century, and Friedrich Engels, who studied the conditions of the English working class, that we create conditions that make people sick, and that those who lack economic, social, and political power typically bear the greatest burden of disease. But more recent work on the impact of inequality on health reveals another truth: inequality is itselfassociated with poorer health outcomes, including lower life expectancies across nations. The coronavirus is about to illustrate that epidemics are great levelers: they can collapse social classes, even if—as with all forms of collapse—the people at the bottom get the worst of it.

The question today is whether we can learn something from coronavirus that might not only help us mitigate the harm of this pandemic, but build a new infrastructure of care that allows us to better protect the most vulnerable—and us all. As the opioid crisis has shown, it is not just infections but all forms of ill health that feed on the weaknesses of our current system, finding the fissures in our social fabric to colonize in and reproduce. The new majority of Americans who see universal health care as a core responsibility of government demand a new politics of care. They seek a new order that, instead of perpetuating the virulent inequality and exploitation of late twentieth-century capitalism, makes justice a core feature of our health care system. Social mobilization is a key tool for achieving these goals. We must demand continuous and sustained reinvestments in our common good.

The press and social media have been awash in stories on the bumbling U.S. response to COVID-19. There is plenty to criticize, and disastrous leadership from the Trump administration may make this much worse than it needs to be. Yet many of the features that threaten to make COVID-19 so disruptive have much longer and deeper roots in our political and social order. This is nowhere more apparent than in the structural features of our health care and public health sectors that make an effective response so difficult.

While many European countries established some sort of compulsory health insurance at the end of the nineteenth century, leading to universal health care programs across the continent, the fight for universal health care in the United States has always been an uphill battle. Attempts have repeatedly been tarred as un-American: it was called the “Prussian menace” during World War I and a “red” menace for most of the rest of the twentieth century, in opposition led, at different times, by either the American Medical Association or the health insurance industry, sometimes by both.

Efforts to expand health coverage across the United States have also always run into the country’s deep commitment to white supremacy and racism. For instance, in the 1940s, Southern Democrats conditioned their votes for the Hospital Survey and Construction Act on a rule that states be allowed to allocate resources locally, so that they could drive new hospital construction away from African American communities. When the Supreme Court willfully gutted the Affordable Care Act’s provision mandating the expansion of Medicaid to low-income Americans in all U.S. states, only some states took advantage of this sterling opportunity to deny their own citizens health coverage that was 90 percent funded by the federal government. In those that did, more than half of those who would have benefitted from the expansion were people of color. A similar fact underlies decisions in some states under the Trump administration to institute work requirements and other barriers to care.

For their part, insurers, hospitals, and the pharmaceutical industry were always all in for a decentralized and weak system. A unified, national health system would give the state the power to bargain for lower costs, using its monopoly on care to face off against companies’ monopolies for profit. It would also allow for standardization and rationalization of services—setting ceilings for charges for procedures and commodities—and for the evaluation trade-offs between the costs and effectiveness of the interventions we simply just add to our theoretically limitless “choice” of health care options today. That choice, of course, is illusory for many.

Today, because conservatives, insurers, and racists have done their utmost to block what most other industrialized countries have had for decades, we lack anything that properly could be called a health care “system.” Instead, we have a sea of different insurers and programs, in which both the amount and quality of coverage are determined by who you are and where you live. The resulting arrangement all but guarantees an inadequate national response to a national crisis—rather than one that is coordinated and coherent, able to take advantage of synergies and economies of scale in supply chain management and other operational tasks, to share essential information on the number of cases and their clinical course, and to disseminate emerging knowledge on the best way to care for the sick.

Indeed, our health system has a laser-like focus on maximizing profit—one that, in the name of reducing the cost of care, has given us fewer hospital beds per capita than China, South Korea, or Italy, a paucity of primary care physicians to manage patients’ basic needs, and a glut of overpriced specialists. Out-of-pocket costs for patients have grown steadily since the 1970s, and averaged more than $1,000 per person in 2018. The average ER visit clocks in at around $500 in out-of-pocket costs. Many insurers establish sharp penalties for seeking care outside of their approved networks.

On top of that, our system constantly seems to produce more byzantine rules to exploit and extract more surplus from the sick. (The latest are “surprise medical bills”—bills that follow care in a facility that is in-network for services performed by a provider, say an anesthesiologist, that is out-of-network.) One in five Americans cannot pay their monthly bills in full, and 40 percent do not have the savings needed to cover an unexpected $400 expense. It is no surprise then that any interaction with our health care system can pose a grave financial risk to most Americans.

So much for those who are insured. Then there are the 27.5 million people who are uninsured. Republican attacks on the ACA have further exacerbated this gap, fueling an 8.5 percent increase in the uninsured population since 2010. Conservatives worked hard to bring this about, always implying that the safety net they were shredding was for someone else—someone darker, at a distance, and less deserving. But as coronavirus is here to tell us, even those who think they can opt out by virtue of their wealth or status rely on public health infrastructure that keeps us all healthy and safe. This has always been the essential logic of universal provision.

Why should the attendees of Aspen, Davos, and the Conservative Political Action Conference (CPAC) last week in Maryland care about our fragmented and weak health care infrastructure? For one thing, it makes it more likely that hospitals around the country will be inundated with a wave of sickness, upending anyone in critical need of health care for COVID-19 or anything else in its wake. (Exactly this situation has already begun to unfold in parts of Italy.) People who are uninsured that need care will have no primary care doctor to turn to, and will belatedly present to overburdened ERs. States and localities are desperately scrambling to make plans to direct only those with the gravest illness to hospitals, knowing that they already face the prospect of an unmanageable surge in demand. Not only the uninsured, but also many with insurance, will likely delay care, presenting only when their cases become catastrophic.

People who cannot get early care will get sicker: more of them will need the ventilators and advanced nursing care that are already being rationed in places like Italy, which looks to be perhaps a week or two ahead of us in the epidemic curve. And these delays in care mean more infectious people in our communities further spreading the virus rather than being in facilities that can care for them while isolating them from the uninfected. Perhaps for this reason Trump and Pence recently signaled that they are considering using federal disaster money to pay hospitals and doctors who care for the uninsured, but this is “clean-up” for a disaster their party put in motion. What did they think would happen with the uninsured in a pandemic? Likely they didn’t think about this at all, preferring their cult-like devotion to small government above any encounter with what scientific facts could clearly show—that pandemics would recur. It was in 1986 that Ronald Reagan said, “The nine most terrifying words in the English language are: I’m from the Government, and I’m here to help.” Terrifying to whom? Not the recipient of help, it seems, at least where that recipient is a congressman. Today three of them—all Republicans, it turns out—are in voluntary self-quarantine, after being informed by public health contact tracing that they were exposed to coronavirus at CPAC.

Finally, this shambolic patchwork of a health care system, which purposefully disadvantages poor communities, communities of color, and immigrants, means millions potentially affected by the coronavirus outbreak will be on the outside looking in, ineligible for care or facing economic or other hurdles to obtaining it. Undocumented immigrants are not eligible to use Medicaid or to purchase coverage through the ACA marketplaces. Under the new “public charge” rule, if immigrants receive Medicaid they may jeopardize their chances of receiving a green card or other permanent status, creating a huge population of people who cannot access or are discouraged from seeking care. Immigrants need to become “self-sufficient,” the Trump administration announced when publishing the rule. This is quintessential, undiluted neoliberalism—waving the Thatcherite flag that “people must look after themselves first,” all the while building a structure to better extract care, work, and surplus from those cut loose from social support.

Then there are the implications of the austerity budgets of recent years. The groundwork for this kind of fiscal policy is bipartisan folly. Ever since Bill Clinton said in his 1996 State of the Union address that “the era of big government is over,” Republicans, and their centrist allies among the Democrats, have made deficit reduction a bipartisan sign of prudence and responsibility in governance. Pete Buttigieg called just last month for a renewed focus on the federal debt for a new generation of Democratic fiscal hawks. But this genuflection to fiscal conservatism as a marker of policy seriousness has real costs, which have dire implications for the response to coronavirus.

Let’s look at the agency in charge of protecting our nation from threats like the one we’re facing now. Funding for the U.S. Centers for Disease Control and Prevention (CDC)—more than half of which goes out to states, cities, and towns—has decreased by 10 percent over the past decade. Meanwhile seventeen states, along with the District of Columbia, have cut their health budgets over the past few years, and 20 percent of all local health departments have done the same. In fact, over 55,000 jobs at local health departments have been lost since 2008. And yet, when Trump was asked in a press conference on February 26 whether the coronavirus crisis had given him pause over the cuts his administration has called for to the CDC, NIH, and WHO, he downplayed the long-term implications of retrenchment. “Some of the people we cut, they haven’t been used for many, many years,” he replied. “You know, I’m a business person, I don’t like having thousands of people around when you don’t need ’em. When we need ’em we can get ’em back very quickly.”

Furthermore, CDC’s Public Health Emergency Preparedness (PHEP) program, the key financing mechanism for state and local public health emergency preparedness, has been cut by a third since 2003. To make matters worse, the president’s 2021 proposed budget slashes $25 million from the Office of Public Health Preparedness and Response, $18 million from the Hospital Preparedness Program, and $85 million from the Emerging and Zoonotic Infectious Diseases program. Given the current outbreak of coronavirus, Congress will surely restore this funding, but all of this underscores a bipartisan trend for most of this century to underfund our nation’s public health in the name of deficit and debt reduction.

If the fortunes of federal, state, and local public health programs have suffered under both parties over the past few decades, where the parties split is on the role of expertise in government. A lot has been written about the regressive politics of neoliberal technocracy, which pushes bold, structural reforms aside for technical tweaks and fixes. But there are parts of the state that depend deeply on expertise, especially public health.

In the context of the coronavirus response, the degradation of expertise in the Trump administration has been catastrophic. It has been difficult to watch CDC director Robert Redfield pander to the commander in chief day-after-day as this crisis unfolds. There are experts who are surely ready to do the right thing—many of the career civil servants in Atlanta are superb public health physicians, scientists, and practitioners—but the administration’s course on coronavirus seems to be more responsive to a president worried about reelection and about bad news that might derail his chances in November than the virus in their midst. In fact, most of the appointed health officials in the administration, from Secretary of Health and Human Services Alex Azar to Surgeon General Jerome Adams, have emerged as cheerleaders and sycophants, aiding and abetting the disinformation coming out of the White House by their refusal to correct the president’s errors in real time.

The basic organizing ideology of U.S. governance also works against the best scientific response when it comes to treatments and vaccines. A vaccine is at least a year off, and may well come too late to have any real impact—yet Azar, a former Eli Lilly CEO, is already promising that the United States will fund the vaccine but has resisted any guarantees of access. Even in a crisis, capital squeezes what it can out of the public, while never seeing the arrangement as a two-way street.

Treatments could have a more immediate impact, but at what cost? Drug prices have spiraled out of control because the United States also lacks any systematic means to control them. This too is no accident. Obama decided that he needed Big Pharma as an industry ally, so refused to take them on during the ACA fight. When we expanded drug coverage in Medicare, the industry extracted a provision that forbids the government from negotiating prices. Measures such as generic competition, which can be invoked under existing law if the administration were serious about bringing the industry to heel, could bring prices down. But they are not being used. Under pressure from industry, the FDA also refuses to share some corporate data with researchers and the public, even where it has clear public value: data that, for example, identifies COVID-related drug shortages, or would help us verify the results of tests of drug safety and efficacy that are conducted by industries that stand to gain billions from the results.

All of these conditions are the byproducts of a system organized by a rapacious concern for profits, and infected with a reflexive suspicion of the government—even though government is the only tool that we have to invest in the long-term science and public health tools that we need to protect us in a pandemic.

Where do we go from here? The seeds of the solution can be found in proposals like Medicare for All. What is missing from the proposals and plans from the progressive wing of the Democratic Party, and even from those of democratic socialists, is what we might call a New Deal for Public Health. This is where social movements can be of great help. The AIDS movement of the past forty years, in particular, offers a template for what we should reach for and the kinds of mobilization we’ll need to achieve our goals.

What might that include? The Medicare for All component has been well mapped out, but less obvious, and just as crucial, is a new infrastructure of care. Envisioning a better, more just, and fairer response to coronavirus points us to what a new future would look like. Ten days ago we joined a group of experts in writing an open letter to our federal, state, and local leaders, setting out the vast range of responses that we need to quickly expand our social immunity and protect the most vulnerable. It highlights many of the things that we need to do, but also need to abstract from to bring about a new politics of care.

If we are to have any real hope of slowing the virus enough to protect our health care system and health care workers, we need a critical mass of people to be in a position to follow the most important measures. For example, people need to be able to stay home when they are sick—and some of those who are sick will need family to care for them. But employment in this country systematically marginalizes our ability to care for ourselves and others. This burdens women, especially immigrant women and women of color, the most, for they are the ones with the highest burdens of care, whether it is paid or unpaid. The truth is stark: almost 30 percent of private sector workers in the United States—and 69 percent in the lowest-wage jobs—have no sick pay. The risk of job loss and precarious scheduling all add to the difficulties for employees. Without anything like universal sick pay or income insurance, self-employed and gig economy workers are entirely cast adrift at a time like this.

The risk is extraordinary for those who are caring for others—the fast food workers and orderlies and nursing home workers that will have no choice but to continue to work. Because they care for us, their risk is our risk too. How will it be possible to contain the spread of this in nursing homes, if their staff can’t both stay home and pay next month’s rent? We already know that paid sick leave in fact slows the spread of epidemics like influenza. Other kinds of social support—not only paid leave, but food and rental assistance, too—are essential in a pandemic, when ordinary forms of income may be unavailable. Italy recently announced a broad moratorium on debt repayment, including mortgages, and Hong Kong plans to make direct payments to all citizens to aid in the response.

Temporary measures like these will help, but it is broader social support that is needed in the long term—not just to combat this particular pandemic, but also to address the staggering burden of chronic disease in this country. Though we often attribute good health to the availability of health care, it is structural forces that have the most impact on health. While we spend enormous amount on health care in this country, it is the weakness of our underlying system of social welfare that differentiates us from other countries with better health outcomes. The social safety net that Republicans and neoliberal Democrats love to hate is what undergirds successful health systems, and rebuilding it will be the foundation of a New Deal for Public Health.

Finally, the United States has shunted millions of people out of the circle of care—casting them out, like the immigrants being rounded up by Immigration and Customs Enforcement; or locking them up, like the millions of incarcerated men and women in our prisons and jails; or throwing them on the street, like the hundreds of thousands of people without a home. These are among the most vulnerable in this epidemic. Immigrants won’t come forward for care if they fear deportation. Those in our prisons and jails are at significant risk of infection, and many, if not most, of the homeless have nowhere to go, with the few homeless shelters woefully unprepared to handle such a crisis. As Anand Giridharadas recently said: “Your health is as safe as that of the worst-insured, worst-cared-for person in your society. It will be decided by the height of the floor, not the ceiling.” Unless we bring everyone into the circle of care in the United States, we will all be vulnerable.

COVID-19 is a crisis of social solidarity and social investment. It has been fifty years since Goldwater and the rise of the right, which has told us, again and again, these things don’t matter. Now with the coronavirus outbreak, we see that, in fact, it’s a matter of life and death and has been all along. Coronavirus has shined a light on the cruelty of American life as it has been constructed for much of our lifetimes. We can’t look away now. Will we?

Will Americans move on from this current crisis in a year, and forget about what this epidemic is revealing about us? Or will we mobilize for health justice, for a New Deal for Public Health, knowing that the forces of reaction will sweep in always to protect capital and its interests above all? We’ve seen a new generation of progressives rise up among our youth, and this creates new possibilities, if those of us in older demographics—those most vulnerable to diseases like COVID-19—join in.

We may make our way out of this pandemic with less death, less damage than we think. But as James Baldwin reminded us, God gave Noah the rainbow sign: no more water but fire next time. This crisis should serve as a warning that the struggle we face is not only political, but existential—with pandemics and plagues, global warming and climate disaster waiting just around the bend, coming whether we learn their lessons in time, or not.